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Antihypertensive use during pregnancy is relatively common and increasing. The wide range of agents
used during pregnancy includes medications considered contraindicated during pregnancy. The choice of
antihypertensive agents is less complex because only a small proportion of currently available drugs have been
evaluated adequately in pregnant women and many are contraindicated7. The present study focused on the
antihypertensive drug utilization pattern in women attending the antenatal clinic of obstetrics and gynaecology
department at a tertiary care teaching hospital.
MATERIALS AND METHODS
A prospective study was conducted over a period of one year in inpatients of Gynaecology and Obstetrics
Department at Bharati Hospital, Pune. All pregnant women attending the antenatal clinic were screened for
hypertension and patients diagnosed as hypertensive disorder of pregnancy were taken for primary evaluation.
The data regarding demographic details, presenting complaints, gestational age, obstetrics history, diagnosis,
blood pressure monitoring, current medications, antihypertensive drugs prescribed were gathered from medical
record files. The utilization of antihypertensive drugs in pregnancy was evaluated.
RESULTS
During one year study, 1330 pregnant women visited the OGD, out of which 104 patients were diagnosed with
hypertension. The prevalence of Hypertensive Disorders of Pregnancy was 7.8%. The mean maternal age at
delivery was 23.8 years. Total distributions of patients with respect to age group shows that highest number of
patients was found in the age group of 18-22 years (41.3 %) and least was above 32 years age group (3.8%).
Table 1 provides various hypertensive disorders in the age groups of patients.
TABLE 1: AGE DISTRIBUTION ACCORDING TO HYPERTENSIVE DISORDERS OF PREGNANCY
The Subject characteristic of woman who were diagnosed as a hypertensive having an average weight of 61.8 kg
and a mean gestational age 32.7 weeks at the time of admission. The mean Systolic Blood Pressure was 156.6
mmHg, while the mean Diastolic Blood Pressure was 101.4 mmHg (Table 2).
Preeclampsia was the most common cause of hypertension during pregnancy (71.2%). This was followed by
Gestational Hypertension (19.2 %) population. Results are summarized in Figure 1.
40 38.5%
35 32.7%
30
Gestational
25 hypertension=20
19.2%
20
Mild preeclampsia=34
15
10 7.7%
1.9% Severe preeclampsia=40
5
0 Eclampsia=8
Chronic hypertension=2
Gestational age at the time of admission varied from 21 weeks till term (Table 3).
In this study, the incidence of hypertension in pregnancy was highest among primigravidae. Out of 104 patients,
56 were primigravida (53.8 %) and 48 were multigravida (46.1%) (Table 4).
No. of patients
Multigravida 8 36 2 2 46.1
Primigravida 12 38 6 -- 53.8
Headache in 20 (19.2%), Epigastric pain in 18 (17.3 %), peripheral edema in 14 (13.5 %), Blurring vision in 2
(1.9 %) patients were observed and Seizures were seen in 4 patients (Table 5).
TABLE 5: SYMPTOMS OF PATIENTS WITH HYPERTENSIVE DISORDERS OF PREGNANCY
Overall 34 (32.69%) patients were treated with a single antihypertensive drug, and 70 (67.31%) patients were
treated with antihypertensive drug combinations as represented in Figure 2.
32.69% Monotherapy=34
Combination
67.31% therapy=70
Figure 3 shows the details of patients, who were treated with a single antihypertensive drug. 18 (17.3 %)
patients were treated with centrally acting antiadrenergic drugs and 16 (15.4 %) patients were treated with
Calcium Channel blockers (Figure 3).
FIGURE 3: THE PATTERN OF USE OF ANTIHYPERTENSIVE DRUGS IN PATIENT TREATED WITH MONOTHERAPY
Centrally Acting
Antiadrenergic
drugs= 18
15.4% 17.3%
Calcium Channel
blockers=16
Table 6 shows details of patients treated with combination therapy, out of 70 patients, 52 (50.0 %) were
prescribed with two drugs, 16 (15.4%) were prescribed with three drugs and 2 (1.9 %) with four drugs. The
calcium channel blockers and centrally acting antiadrenergic drugs (28.8%) was the most frequently prescribed
two-drug combinations. β-blocker agent, Calcium channel blocker and centrally acting agent (15.4 %) was the
most frequently prescribed three drug combinations (Table 6).
TABLE 6: THE PATTERN OF ANTIHYPERTENSIVE DRUGS IN PATIENT TREATED WITH COMBINATION THERAPY (N= 70)
The most commonly prescribed antihypertensive drugs were Methyl dopa & Nifedipine (28.8 %); Methyl dopa
(17.3 %), Nifedipine (15.4%), Labetalol, Nifedipine & Methyldopa (11.5 %) as represented in Table 7.
The most commonly prescribed medication classes were calcium supplement (92.3%), iron preparations (44.2%),
nutrient supplements (40.4%), multi vitamins (38.5%), and folic acid (32.7 %) as represented in Table 8.
TABLE 8: DRUG UTILIZATION PATTERN IN OB&GY INPATIENTS OTHER THAN ANTIHYPERTENSIVE DRUGS
DISCUSSION
Hypertensive disorders of pregnancy are considered to be a major worldwide health problem running
an increased risk of Perinatal and maternal mortality1. The prevalence of Hypertensive Disorder in Pregnancy
varies according to geographic regions of world and ranges from 1.5% in Sweden’s to 7.5% in Brazil8.
According to our study, the frequency of hypertensive disorders of pregnancy was 7.8%. The variations can be
attributed to racial differences, socioeconomic status and some other parameters like parity and age.
The distribution of different hypertensive disorders of pregnancy was that, Gestational hypertension of
pregnancy was diagnosed in 20 (19.2%) cases. 74 patients (71.1%) and 8 (7.7%) patients appeared to be pre-
eclamptic and eclamptic respectively. In India, the incidence of preeclampsia is reported to be 8-10% of the
pregnancies9. We also observed preeclampsia in 5.4% of the study population. The overall prevalence of
Eclampsia in our study was found to be 0.6 % of pregnancies. The reported incidence of eclampsia from India
is 0.71 %. These figures are comparable with our study. Chronic hypertension was found 2 (1.9 %) patients in
our study. The frequency of chronic hypertension in Iran was 0.17% which is similar to our study (0.15 %) 10.
Age has an important influence on the incidence of hypertensive disorders of pregnancy. Young
primigravidae under 20 years and all patients over 30 years have an increased chance of hypertension 11. In our
study highest incidence of the hypertensive disorders occurred among those aged 18 to 22 years. This could be
because the majority of conceptions take place in this age group in our country. The age distribution of
eclampsia patients in our study is similar to other reports and suggests that eclampsia is, probably, a disease of
young women12. Preeclampsia is more frequent in patients younger than 21 years of age and in older than 35 13.
In our study majority of preeclampsia patients were between the ages of 18 to 22 years. Preeclampsia and
eclampsia were apparently higher in younger pregnant women (less than 30 years) as Yucesoy et al, showed in
their recent investigation. The frequency of chronic hypertension appears to be higher in woman aged ≥30 10
years & same is indicating in our study also.
The incidence of PIH is distributed unevenly throughout late gestation, increasing with advancing
gestation. Approximately half of PIH cases occur at term ≥37( weeks' gestation), including most cases of
gestational hypertension. Early-onset PIH is often associated with severe preeclampsia 14. The mean gestational
age at presentation was 32.7 weeks which is comparable with other study (i.e. 37 weeks) 15. The reported
gestational age of onset of preeclampsia is more than 20th week of pregnancy in vast majority of patients, but
recently a case was reported from Japan with typical features of preeclampsia occurring at less than 20th weeks
of gestation15.
Preeclampsia is primarily regarded as a disease of first pregnancy. In our study, 53.8% were
primigravidas and 46.1 % were multigravidas. Several other authors have reported primiparity in 52-73%
patients of preeclampsia. In our study, both primigravida and multigravida were equally affected with
eclampsia. But literature indicates that eclampsia is a disease of primigravida. According to Hellman incidence
of eclampsia in primigravida and multigravida was in the proportion of 3:116.
Oedema was seen in 13.5 % of our patients. Oedema is a very common manifestation seen in upto 80%
of normal pregnancies17. Prevalence of peripheral edema was significantly less than what would be expected.
We believe that this might have been due to all information was not necessarily documented.
Antihypertensives are agents that lower blood pressure. The aim of antihypertensive therapy in the
management of pregnancy induced hypertension is to prevent complications due to hypertension while
prolonging the course of pregnancy. Monotherapy and combination therapy were used in our hospital for
treating hypertension during pregnancies. The most commonly prescribed antihypertensive agent was adrenergic
receptor alpha-2 agonists: Methyldopa, Nefidipine, Labetol. The use of combination antihypertensive
pharmacotherapy suggests increased Severity of illness where optimal BP control cannot be achieved on
monotherapy. The present study reveals that adrenergic receptor alpha-2 agonists (Methyldopa) were mostly
prescribed single drug therapy. In the present study, two drug combinations were mostly prescribed (49.8 %)
followed by three drug combinations (15.4 %). In the present study also most of the cases of PIH were treated
using Methyldopa or Nifedipine. Methyldopa was the commonest prescribed antihypertensive as monotherapy
as well as in combination therapy. Similarly in a study by Cvijic M et.al18, Methyldopa was most commonly
prescribed antihypertensive drugs in 27.8% of patients. In contrast to this, studies from Ray JG et.al19 showed
that Nifedipine (47.7%) was prescribed more frequently than Methyldopa (27.7%).This shows that utilization
pattern differs from hospitals, prescribers and among countries also.
In our study, calcium supplements, iron preparations, nutritional supplement, folic-acid and Vitamins,
the most frequently used drugs in pregnancy. Periconceptional folic-acid supplementation can prevent most
neural-tube defects and other congenital abnormalities of the cardiovascular system, urinary tract and limb
deficiencies. Moreover, folic-acid supplementation in pregnancy is associated with the decreased incidence of
habitual spontaneous abortion and pregnancy complications (e.g., placental abruption and preeclampsia) 20.
CONCLUSION
Our study concluded that the incidence of hypertensive disorders in pregnancy was high. Early
diagnosis and treatment through regular antenatal checkup is a key factor to prevent PIH and its complications.
The incidence of combination therapy was high. Methyldopa was the commonest prescribed antihypertensive in
monotherapy and combination, as it is safest during pregnancy.
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